问题3:什么是肘关节“恐怖三联征”?

解答:1996年,Hotchkiss首次提出了肘关节"恐怖三联征"的概念,后被逐步定义完善,即:肱尺关节后脱位伴有尺骨冠状突骨折、桡骨小头骨折及外侧副韧带损伤,此外还可能存在内侧副韧带、伸肌腱起点、前臂屈肌、旋前圆肌起点损伤或肱骨小头、滑车切迹等骨、软骨损伤。肘关节"恐怖三联征"多见于交通事故伤和坠落伤,最常见的损伤机制为高处坠落时肘关节在伸直     

运用MRI对肱骨外上髁炎的综合性评价

目的 探讨肱骨外上髁炎MRI的综合表现.方法 对经临床诊断的23例肱骨外上髁炎患者共24个肘关节分别行MRI检查,按伸肌总腱损伤程度分为轻、中和重度,观察患者是否合并其他损伤,包括桡侧尺副韧带损伤,桡侧副韧带损伤,内侧副韧带损伤,伸肌损伤、骨质损伤、关节腔积液、肱二头肌腱损伤等.将韧带的损伤分为轻、中和重度三级.对伸肌总腱和桡侧尺副韧带的损伤程度作Spearman等级相关分析,P＜0.05认为有显著相关.结果 伸肌总腱轻度损伤10例,中度7例,重度7例.合并桡侧尺副韧带损伤22例(轻度9例,中度6例,重度7例),桡侧副韧带损伤8例,内侧副韧带损伤3例,伸肌损伤7例,骨质损伤5例,关节腔积液6例,肱二头肌腱损伤1例,肘肌损伤7例.伸肌总腱与桡侧尺副韧带的损伤程度呈正相关(r,=0.852,P＜0.01).结论 肱骨外上髁炎并非单一的伸肌总腱病变,多合并其他改变,并且随着伸肌总腱损伤的加重,桡侧尺副韧带损伤也加重,对诊疗具有重要的指导作用.     

桡骨头骨折合并尺侧副韧带损伤的手术治疗

目的 分析桡骨头骨折合并尺侧副韧带损伤的治疗方法及其疗效. 方法 对2004年8月-2011年1月收治的桡骨头骨折伴尺侧副韧带损伤行手术治疗的38例患者进行随访,其中24例获得随访且资料完整.按改良Mason分型:Ⅱ型6例,Ⅲ型15例,Ⅳ型3例.分别采用普通螺钉、Herbert钉、空心螺钉、可吸收钉及微型钢板固定,骨折粉碎严重行桡骨头置换术.侧副韧带复合体的修复采用直接缝合,如不能缝合则重建韧带. 结果 本组获得10～ 84个月随访,平均37.1个月.按Mayo肘关节功能评分评定:优18例,良4例,一般2例,优良率为92％.结论 对于MasonⅡ型以上的桡骨头骨折合并尺侧副韧带损伤患者,应首选桡骨头重建术,不能重建应行桡骨头置换.桡骨头重建术中在修复其他合并损伤后肘关节仍出现外翻不稳定,应对尺侧副韧带进行修复或重建.桡骨头置换术中应Ⅰ期修复及重建肘关节桡尺侧副韧带.     

急性复杂性下尺桡关节脱位一例

患者　男,45岁。1998年2月因坠落伤致骨盆骨折、失血性休克。入院后予抗休克治疗,3天后,病情趋于稳定。自诉左腕部疼痛,前臂旋转受限。体检:左腕部畸形,与正常侧对照,背侧尺骨小头隆起部分消失,前臂旋前障碍。Ｘ线摄片示“前臂无骨折及脱位”,腕部轴位ＣＴ检查示“下尺桡关节脱位,掌侧脱位”。予手法多次复位未成功,被动旋转前臂时,尺桡骨之间有软绵绵的感觉。1周后在臂丛麻醉下行手术切开复位术。取背侧切口,于尺侧腕伸肌桡侧直切口,保护尺神经背侧分支感觉支。术中见尺侧腕伸肌嵌入尺桡骨之间,用血管钳将此肌腱轻轻向背侧提起,配合手法牵…     

肘关节周围韧带肌腱附着处骨化对氟骨症的诊断价值

目的 探讨肘关节周围韧带肌腱附着处骨化对氟骨症的诊断价值.方法 分析2011-03在燃煤型地氟病区人群调查中发现的23例氟骨症氟性肘关节病患者的肘关节X线征象.结果 肱骨内、外上髁肌腱附着处骨化各7例,桡骨头环状韧带骨化6例,肘关节间隙狭窄18例,肘关节面下骨小梁粗大或细密改变10例,肘关节面下骨质囊性变4例,滑车外侧骨嵴骨赘形成4例,肱尺关节内缘骨赘形成8例,上尺桡关节相对面骨赘形成3例.结论 桡骨头环状韧带骨化及肱骨内、外上髁屈伸肌腱附着处骨化是氟性关节病具有特征性的重要征象,对氟骨症的诊断有重要意义.     

高频超声在肱骨外上髁炎诊断中的应用

目的 :探讨高频超声在肱骨外上髁炎诊断中的应用价值。方法 :对2013年9月至2014年9月在我院临床诊断肱骨外上髁炎的57例患者,行高频超声切面扫查患侧伸肌总腱,观察肱骨外上髁伸肌总腱的边界、厚度、内部回声、血流分布情况及外上髁骨面是否光整,并与健侧对比检查。常规扫查桡侧副韧带、桡骨环状韧带、肱桡关节间隙。结果:57例均有异常回声表现,其中18例伸肌总腱增厚、边界欠清晰光整,内部可见局灶性无回声区,纤维纹理连续中断,CDFI示局灶无回声区内部见少量血流信号;26例伸肌总腱增厚、边界欠清晰光整,内部呈片状回声减低不均匀,纤维纹理欠清,CDFI示回声减低区域血流信号丰富;3例伸肌总腱仅稍增厚或不增厚,内部回声欠均匀,与外上髁骨面间不规则无回声区,CDFI示不规则无回声区内部无血流信号;10例伸肌总腱增厚、边界不清,内部回声高低不均匀,纤维纹理不清,可见弧形高回声钙化灶伴声影,外上髁骨面粗糙不光整或伴骨刺凸起,CDFI示肌腱内少量血流信号或无血流信号。57例健侧肱骨外上髁对比探查显示,伸肌总腱为纤维带状结构扇形止于肱骨外上髁,边界清晰光整,纤维连续性好,内部回声均匀一致,CDFI示内部无血流信号。患侧肘关节桡侧副韧带、桡骨环状韧带、肱桡关节间隙与健侧对比未发现异常。结论:高频超声能清楚显示肱骨外上髁及伸肌总腱结构与病变情况,能够为肱骨外上髁炎的临床诊断提供客观可靠的依据。     

肘关节骨折-脱位

单纯的肘关节脱位通过非手术治疗可能取得满意疗效,遗留的后遗症较少.而肘关节骨折-脱位即复杂肘关节脱位,即肘关节脱位合并有桡骨或(和)尺骨骨折时,治疗较为棘手,并常需要手术治疗,较容易发生并发症.该损伤可能分为4个常见的类型,确定损伤的类型有助于决定理想的治疗方案.治疗肘关节骨折-脱位的原则包括:(1)恢复肱尺关节,复位肘关节脱位,尺骨近端(冠状突、鹰嘴)骨折的复位内固定;(2)如果肱尺关节不能恢复到正常,通过复位内固定或置换治疗桡骨头骨折,恢复其对肘关节的稳定作用;(3)侧副韧带损伤应该予以修复.     

MR直接关节造影在腕三角纤维软骨复合体损伤中的应用

目的 通过与腕关节镜结果对照,探讨MR直接关节造影在腕三角纤维软骨复合体(TFCC)损伤中的作用.方法 14例临床怀疑腕TFCC损伤的患者接受了常规MRI和MR直接关节造影,其中10例行腕关节镜检查.MR直接关节造影在腕拇长伸肌腱与伸指总肌腱间隙(相当于桡舟关节间隙)处进针,注入5～7 ml的钆喷替酸葡甲胺(0.1 mmol/L)混合液(0.3 ml钆喷替酸葡甲胺+100 ml生理盐水),与腕关节镜结果相对照,分析常规MRI和MR直接关节造影表现.结果 (1)14例中TFCC尺侧撕裂5例,桡侧撕裂4例,整体损伤5例(包括2例长期类风湿关节炎).(2)在脂肪抑制序列(STIR)及T2和T1WI序列上,损伤的TFCC表现为高信号或等信号,正常的低信号部分或完全消失,MR直接关节造影显示4例桡侧撕裂在腕TFCC的下尺桡关节和5例尺侧撕裂在尺骨茎突附着处可见不同程度的高信号对比剂聚集,5例整体损伤在下尺桡关节和尺骨茎突附着处均可见对比剂.MR直接关节造影表现与腕关节镜结果在损伤部位相符合,包括4例桡侧撕裂,3例尺侧撕裂和3例整体损伤.(3)14例腕TFCC损伤患者,8例伴有下尺桡关节半脱位,6例伴有尺桡骨骨挫伤,常规MRI和MR直接关节造影均可清晰地显示其滑膜反应和骨髓水肿等表现.结论 MR直接关节造影可以清晰地显示腕TFCC损伤,同时与常规MRI相结合能显示伴随的滑膜反应和骨髓水肿.     

桡骨远端骨折不同程度背屈畸形后腕动力学变化

目的测定桡骨远端骨折背屈成角畸形后腕动力肌腱的滑动距离和力臂变化,为矫正临床上骨折畸形提供依据. 方法采用7只新鲜成人尸体上肢标本,将桡侧腕长伸肌腱、桡侧腕短伸肌腱、尺侧腕伸肌腱、桡侧腕屈肌腱和尺侧腕屈肌腱与旋转电压计相连,测定肌腱活动距离 ,在桡骨远端、桡骨骨折向背侧成角10°、20°、30°、40°时,分别测定在腕屈曲45°至伸展45°、桡偏20°至尺偏25°过程中5根腕主要活动肌腱距离,用方差分析法分析不同程度桡骨成角时力臂变化的统计学差异. 结果桡骨骨折背屈成角显著影响腕动力肌腱的力臂,骨折畸形程度越大,力臂变化越大.背倾成角10°时即可引起力臂显著变化,背倾30°～40°时力臂变化很大.桡侧伸腕肌腱力臂显著增大,屈腕肌腱力臂显著减小. 结论桡骨远端骨折背屈畸形显著影响腕动力学,临床上即使10°的背屈畸形也需要予以矫正,强调对此骨折完全解剖复位.     

尺骨茎突骨折的治疗进展

尺骨茎突骨折往往与桡骨远端骨折合并存在[1],是临床最常见的损伤之一,但该骨折对下尺桡关节的稳定及功能的影响,与三角纤维软骨复合体损伤是否有关联,乃至与桡骨远端骨折后慢性腕尺侧痛、尺腕关节功能障碍、腕关节活动度减小等晚期后遗症是否有关系等,至今仍有争论.     

Hyperextension trauma to the elbow joint induced through the distal ulna or the distal radius: Pathoanatomy and kinematics: An experimental study of the ligament injuries

Loads applied to the forearm result in hyperextension of the elbow. The pathomechanics of hyperextension trauma with load applied to the distal radius and ulna were studied in 10 macoscopically normal cadaver elbow joint specimens to reveal patterns of injury with radial traction ( n =5) compared to ulnar traction ( n =5). The mean age of the donors was 60.8 years (range 33–74). Kinematic testing was performed in an experimental 3D-kinematic loading apparatus. The extension range of motion increased by 20.9°± 2.9° after joint loading. Hyperextension loads induced joint laxity during flexion of less than 60°. In both groups, the changes were significant in joint flexion during forced valgue and external rotation, but were not significant in flexion during forced varus and internal rotation. In both groups, the same four lesions were produced: 1) Anterior capsule rupture, 2) L-formed rupture of the origin of the pronator muscle with elongation of the anterior bundle of the medical collateral ligament, 3) partial rupture of the lateral collateral ligament and 4) small cartilage damage to the posterior or anteromedial edge of the ulna. In conclusion, hyperextension trauma to the elbow joint induced through the distal ulna or the distal radius produced the same pattern of injury as reported in hyperextension of the elbow with traction to the forearm when free rotation of the radius relative to the ulna was allowed.     

PLRI: posterolateral rotatory instability of the elbow

Recurrent and persistent instability of the elbow has long been a source of confusion and dismay for both patients and physicians. Early recognition after elbow injury and careful attention to soft tissue repair during lateral elbow surgery may diminish the incidence of this condition. Repair and reconstruction of the lateral ulnar collateral ligament (LUCL) now offers practical and often successful solutions for patients with posterolateral rotatory instability (PLRI) of the elbow.     

Magnetic resonance imaging in the evaluation of treatment response of lateral epicondylitis of the elbow

The purpose of this study was to investigate the treatment response in lateral epicondylitis (tennis elbow) by MRI. Magnetic resonance imaging was obtained in 30 patients with clinical symptoms of lateral epicondylitis of the elbow using T1-, T2- and T2-weighted fat-saturated (FS) sequences. The patients were randomised to either i.m. corticosteroid injection (n=16) or immobilisation in a wrist splint (n=14). Magnetic resonance imaging of the elbow was performed on a 1.5-T MR system at baseline and after 6 weeks. The extensor carpi radialis (ECRB) tendon, the radial collateral ligament, lateral humerus epicondyle at tendon insertion site, joint fluid and signal intensity changes within brachio-radialis and anconeus muscles were evaluated on the MR units workstation before and after 6 weeks of treatment. The MRI was performed once in 22 healthy controls for comparison and all images evaluated by an investigator blinded to the clinical status of the subjects. The MR images showed thickening with separation of the ECRB tendon from the radial collateral ligament and abnormal signal change in 25 of the 30 patients on the T1-weighted sequences at inclusion. The signal intensity of the ECRB tendon was increased in 24 of the 30 patients with lateral epicondylitis of the elbow on the T2-weighted FS sequences. In the patients there were no associations between pathologically signal intensity within the ECRB tendon on T1- and T2-weighted sequences and the degree of self-reported pain (Dumbells test) at inclusion. In general, the MRI changes persisted in the patients at follow-up after 6 weeks despite clinical remission. The increased signal intensity within the extensor tendon is indicative of lateral epicondylitis humeri. The changes in signal intensity and morphology of ECRB tendon seem to be chronic and may persist despite clinical improvement.     

Magnetic resonance imaging of the elbow. Part II: Abnormalities of the ligaments, tendons, and nerves

Part II of this comprehensive review on magnetic resonance imaging of the elbow discusses the role of magnetic resonance imaging in evaluating patients with abnormalities of the ligaments, tendons, and nerves of the elbow. Magnetic resonance imaging can yield high-quality multiplanar images which are useful in evaluating the soft tissue structures of the elbow. Magnetic resonance imaging can detect tears of the ulnar collateral ligament and lateral collateral ligament of the elbow with high sensitivity and specificity. Magnetic resonance imaging can determine the extent of tendon pathology in patients with medial epicondylitis and lateral epicondylitis. Magnetic resonance imaging can detect tears of the biceps tendon and triceps tendon and can distinguishing between partial and complete tendon rupture. Magnetic resonance imaging is also helpful in evaluating patients with nerve disorders at the elbow.Part I of this review can be found at:     

Sonographic examination of lateral epicondylitis

OBJECTIVE: The purpose of this study was to describe the sonographic appearance of the common extensor origin in cadavers and asymptomatic volunteers, and to relate this appearance to the findings in patients with lateral epicondylitis. SUBJECTS AND METHODS: Seventy-two elbows in 71 patients with lateral epicondylitis were examined on sonography. Most of the patients (60/71) gave a history of repetitive microtrauma. The injuries were evaluated with respect to location and severity. Focal areas of degeneration, discrete cleavage tears, and involvement of the lateral collateral ligament were identified. Calcification and bony changes were noted. The appearance of the normal common extensor tendon was described, and cadaveric specimens were dissected. Twenty-one patients subsequently underwent surgery. RESULTS: The normal common extensor origin is composed of longitudinal fibrils bound closely with the extensor carpi radialis brevis constituting most of the deep fibers, with the extensor digitorum making up the superficial part. The lateral collateral ligament can be identified as a discrete and separate band. The most common appearance of lateral epicondylitis is a focal hypoechoic area in the deep part of the tendon (46/72). These focal areas were identified at surgery and corresponded histologically to collagen degeneration with fibroblastic proliferation. Often discrete cleavage planes traversing the tendon were manifest as partial (18/72) and complete (2/72) tears. The lateral collateral ligament was involved in eight of 72 elbows. CONCLUSION: Sonography of the common extensor origin can be used to confirm lateral epicondylitis in patients with lateral elbow pain and provide information about the severity of the disease.     

Dual reconstruction of the radial collateral ligament and lateral ulnar collateral ligament in posterolateral rotator instability of the elbow

Recent studies have found that the radial collateral ligament (RCL) plays a key role in the lateral stability of the elbow joint, and there is no truly isometric location for LUCL tendon graft reconstruction tunnels using the original technique. However, no report has been issued on the treatment including RCL reconstruction and the modification of LUCL reconstruction in patients with posterolateral rotatory instability (PLRI). Three patients with PLRI were treated using two different ways and produced good results. First, dual reconstruction of the LUCL and RCL was performed, and second, the insertion of the reconstructed LUCL was shifted to the AL instead of to the original ulna to produce a more flexible isometric point setting. We want to report on the management of PLRI by dual reconstruction of the RCL and LUCL and a modification of the original technique of LUCL reconstruction.     

Percutaneous lateral ulnar collateral ligament reconstruction

Purpose

Open surgical reconstruction of the lateral ulnar collateral ligament is the standard treatment for symptomatic posterolateral rotatory instability of the elbow. It involves dissection and retraction of the lateral elbow muscles, which have been shown to be secondary stabilizers of the lateral elbow. We introduce a new muscle-protecting technique for single-strand lateral ulnar collateral ligament reconstruction and report on the isometry and primary stability when compared with a conventional muscle-splitting procedure. It was hypothesized that percutaneous lateral ulnar collateral ligament reconstruction provided isometry over the range of motion and that stability was comparable with a conventional open procedure.

Methods

In sixteen human cadaver arms, the intact and the lateral collateral ligament complex-deficient situation was tested. Open lateral ulnar collateral ligament reconstruction was performed using a single-strand palmaris graft with humeral and ulnar tenodesis screw fixation. Posterolateral rotational stability was compared with a new reconstruction method, which percutaneously places a single-strand palmaris graft with humeral and ulnar tenodesis screw fixation.

Results

Both open and percutaneous lateral ulnar collateral ligament reconstruction provided isometry over the range of motion and restored posterolateral stability to that of the intact situation. No significant differences between open and percutaneous reconstruction were found.

Conclusions

Percutaneous lateral ulnar collateral ligament reconstruction aims to preserve the lateral elbow muscles and to minimize soft tissue dissection. It has been shown that in an in vitro setup, this new procedure provides isometry over the range of motion and sufficiently restores posterolateral rotatory stability.     

New mechanism of the posterior elbow dislocation

Purpose

To suggest a new model on the most common kind of posterior elbow dislocation using MRI findings on acute elbow injuries.

Methods

Fifteen patients with simple elbow dislocation (Group A) and 19 patients sustaining pure ligament injuries (Group B) were enrolled in this study. Using MRI scans, bony contusion at radial head and posterior capitellum (lateral bone contusion) and medial aspect of the ulnohumeral joint (medial bone contusion) were investigated with the injury patterns of the collateral ligament and overlying muscles. In Group A, the injury patterns of the ulnar and lateral ulnar collateral ligaments were classified into distraction or stripping type; in Group B, into rupture or strain. Based on these findings, we speculated the injury mechanism of the elbow dislocation.

Results

In Group A, posterolateral (PL) dislocation was found in 12 cases of distractive ulnar collateral ligament type and stripping lateral ulnar collateral ligament type, where lateral bone contusion was found in 11 cases. Posteromedial (PM) dislocation was observed in only two cases of distraction type of the LUCL, where medial bone contusion was seen in two cases. In PL dislocation of the elbow joint, we always found more severe damage of soft tissue at the medial side of the elbow joint compared to the lateral side. Lateral bone contusion was speculated to be caused by bony abutment under pathologic forearm external rotation (PFER) and medial bone contusion, by bony abutment under varus stress. In Group B, the ulnar collateral ligament was more commonly injured than the lateral ulnar collateral ligament, and lateral bone contusion accompanied most cases.

Conclusion

PL dislocation is thought to start from the medial side in contrary to PM dislocation beginning at the lateral side. If the disengagement of the coronoid process is not completed due to the insufficient valgus/varus distraction, a coronoid fracture will develop at the same time as the elbow dislocation during PFER.     

Articular and ligamentous contributions to the stability of the elbow joint

This preliminary study of four elbow specimens investigates the relationship of articular geometry and ligamentous structures in providing stability to the elbow joint. A technique is presented that describes the constraining features of varus-valgus and distraction in extension and at 90 degree of elbow flexion. Valgus stability is equally divided among the medial collateral ligament, anterior capsule, and bony articulation in full extension; whereas, at 90 degrees of flexion the contribution of the anterior capsule is assumed by the medial collateral ligament which provides approximately 55% of the stabilizing contribution to valgus stress. Varus stress is noted to be resisted primarily by the anterior capsule (32%) and the joint articulation (55%) with only a small (14%) contribution from the radial collateral ligament. At 90 degrees of flexion, little change is noted in the contribution to the radial collateral ligament (9%), but the anterior capsule offers only 13%, with the remaining stability (75%) arising from the joint articulation. In extension, the soft tissue resistance to distraction is provided minimally by either the radial (5%) or the medial (5%) collateral ligaments, and thus primarily originates from the anterior capsule (85%). At 90 degrees of flexion, however, the capsule offers virtually no resistance to distraction (8%). The radial collateral ligament contributes 10% of the stability, while the medial collateral ligament accounts for 78% of the resistance to distraction in this position. Too few specimens have been studied to form any conclusions for direct clinical applications at this time. However, the technique provides a reliable tool with additional studies for different positions and loading conditions underway. These efforts should disclose useful information that might be applied to the management of chronic elbow instability, radial head or olecranon fracture, the design and implantation of elbow prostheses, or provide a rationale for other reconstructive procedures.     

Ultrasonography of the elbow

Ultrasonography (US) of the elbow is an increasingly utilized modality for a variety of diagnoses. US is advantageous in many cases because of the ability to perform a dynamic examination while obtaining patient feedback. Furthermore, US is cost effective, widely available, and beautifully demonstrates superficial soft tissue structures. Finally, US is an excellent option for patients whose studies are degraded by motion artifact or those with claustrophobia concerns. The most common pathologies about the elbow are discussed in this article, including partial- and full-thickness tears of the biceps and triceps tendons, common extensor and flexor tendinosis, medial and lateral epicondylitis, radial and ulnar collateral ligament tears, ulnar nerve entrapment, cubital or olecranon bursitis, joint effusions, and intra-articular bodies. Relevant anatomy is detailed as it pertains to sonographic evaluation and appearance. In addition, specific imaging techniques and positions are described for optimum visualization of the various structures around the elbow because US is highly operator dependent.